Uptake of breast cancer screening in older women

Age and Ageing 2000; 29: 131 135 Uptake of breast cancer screening in older women NIA I. EDWARDS, DEE A. JONES 1 University Department of Geriatric Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, North Wales LL18 5UJ, UK 1 University Department of Geriatric Medicine, University of Wales College of Medicine, Academic Centre, Llandough Hospital, Penlan Road, Cardiff, South Glamorgan CF64 2XX, UK Address correspondence to: N. I. Edwards. Fax: (+44) 1745 534668 2000, British Geriatrics Society Abstract Objectives: to determine breast screening uptake in older women and to ascertain from previous non-attenders whether they would accept screening if invited. Design: a random sample of older women randomly selected from three Family Health Service Authorities were interviewed in their homes. Participants: 1604 women aged 65 years and over living at home, a response rate of 94%. Results: 120 respondents (8%) had previously been screened. Rates were higher among those who were married, separated or divorced than those who were single (P < 0:01). Of those who had not previously been screened, 742 (50%) reported that they would attend if invited. Age influenced potential attendance: 67% of those aged 65 69 would accept compared with 27% of those aged 80 and over (P < 0:0001). Future attenders were significantly more likely to belong to the upper social class and to be currently married, and were significantly less likely to be disabled or depressed, but more likely to be anxious (P < 0:05). Conclusions: it is unjustifiable to exclude women over 65 from breast screening on the basis of assumed low uptake rates. Certain categories of women such as those who were physically disabled, depressed, single or from lower social classes could be targeted to achieve maximum uptake rates. Keywords: breast cancer, mortality, screening Introduction Screening is the identification of preclinical disease by a relatively simple investigation. There are several prerequisites for successful screening [1], but the ultimate objectives are to reduce mortality or morbidity, or to improve quality of life. The incidence of carcinoma of the breast ranges from 160 per 100 000 in 50 64-year-old women to 200 per 100 000 in the 65 74-year age group, with mortality rates varying similarly [2]. In the United Kingdom, 59% of deaths from breast cancer occur in women aged 65 years and over [3]. The establishment of the UK breast screening programme occurred after the publication of the Forrest Report in 1986 [4]. The report accepted that the most important risk factor for breast carcinoma is age [5 7], but recommended that, in view of poor acceptance rate in older women in the Swedish Two Counties study [8] and the Nijmegen study [9], insufficient population benefit was to be gained by actively offering screening to women aged 65 years and over. The priority of the UK breast screening programme was to offer an initial screen to women between 50 and 64; screening for those aged 65 years and over would be available only on demand. Criticism of this upper age limit has been considerable. Age Concern considers that current policy discriminates unfairly against older women and has no firm basis in research [10, 11]. The 14-year follow up results of the Swedish Two Counties trial [12] and 13- year follow-up case control study of the Nijmegen programme [13] revealed that the reduction in breast cancer mortality attributable to mammographic screening amongst women aged 65 74 years may be as much as 55%. Subsequent analysis of the Two Counties trial found screening to be more effective in terms of lives saved in women aged 65 74 years [14]. Breast screening is cost-effective, with about one-third of all costs being offset by a decreased treatment in advanced disease [15, 16]. Knowing how many women aged 65 and over have had or would be willing to undergo breast screening is important as UK government policy is to await the 131

N. I. Edwards, D. A. Jones results of three ongoing pilot studies before considering the extension of screening to women over 65. This is despite a recommendation that the age at which women be invited for screening should be increased to 69 years [17]. The aims of our study were to investigate previous history of breast screening and potential uptake of screening were it to be offered in the future among a large random sample of women aged 65 years and over. Methods This study of breast screening in women over 65 was conducted as part of a larger study of the health and well-being and use of services by representative samples of older people [18]. We selected a random sample of 1000 people aged 65 years and over from each of three Family Health Service Authorities registers in Wales. The sample reflected the general population of England and Wales, when compared with Webber and Craig s review of socio-economic classification of local authority populations [19]. Trained, experienced field workers interviewed participants in their own homes. The interview schedule asked the women not only whether they had ever undergone breast screening, but also if they would wish to attend if invited. Age, social class, marital status and living arrangements were ascertained and functional and physical disability was assessed by a validated questionnaire [20]. Anxiety and depression were assessed by the Symptoms of Anxiety and Depression Scale, which focuses exclusively on symptomatology within the previous month and has been adapted for use in older populations [21]. We performed statistical analysis of the data by the x 2 test and the Mantel Haenszel test for trend, with a P value of <0.05 being defined as significant. Further details of the methodology have been published previously [18]. Results Of 1706 women selected, 1604 were successfully interviewed, giving a response rate of 94%. A total of 401 (25%) were aged 65 69, 816 (51%) were aged 70 79 and 387 (24%) were aged 80 years and over. History of previous breast screening We found that 120 (8%) women had previously undergone screening. There was a significant association with age, with more younger women having been screened (P < 0:001; Table 1). Attendance varied significantly with marital status: 10% of the married women and 9% of those who were separated or divorced had been screened, compared with 6% of those who were single (P < 0:01; Table 1). Living arrangements were also significantly associated with breast screening uptake: 11% of women living with their husbands had attended but only 7% of those who lived alone (P < 0:0001; Table 1). Social class, current anxiety and depression and disability were not significantly associated with previous uptake of breast screening. Future uptake of breast screening Respondents who were previous non-attenders were asked if they would undergo breast screening if invited: 742 (50%) reported that they would do so. Age significantly influenced acceptance rate: 67% of those aged 65 69 would accept compared with 53% of those aged 70 79 and 27% of those aged 80 or older (P < 0:0001; Table 2). Social class also influenced responses: 62% of women in social class 1 would accept compared with 35% of those in social class V (P < 0:05). Table 1. Previous uptake of breast screening in older women Previous breast screening... Yes No...... Number % Number %... Age (years), n ¼ 1604; P < 0:0001 65 9 63 16 338 84 70 9 46 6 770 94 80 11 3 376 97 Social class, n ¼ 1565; NS I 5 10 45 90 II 28 11 225 89 III 64 7 892 93 IV 15 7 202 93 V 5 6 84 94 Marital status, n ¼ 1604; P < 0:01 Married 64 10 576 90 Single 6 6 100 94 Separated/divorced 5 9 54 92 Widowed 45 6 754 94 Living arrangements, n ¼ 1604; P < 0:0001 Alone 51 7 670 93 Spouse only 60 11 496 89 Spouse þ others 4 5 83 95 Others 5 2 235 98 Anxiety, n ¼ 1576; NS Present 27 7 368 93 Absent 93 8 1088 92 Depression, n ¼ 1576; NS Present 11 5 192 95 Absent 106 8 1264 92 Disability, n ¼ 1603; NS None 33 10 309 90 Some 48 7 640 93 Appreciable 21 8 240 92 Severe 18 6 294 94 NS, not significant 132

Breast cancer screening Future acceptance of breast screening also varied with marital status: 60% of married women would accept compared with 43% of those who were widowed and 40% of those who were single (P < 0:0001; Table 2). Living arrangement would also influence potential acceptance of breast screening: 61% of women living with a spouse only would accept compared with 36% of those who lived with others (P < 0:001; Table 2). Of those women with anxiety, 56% would accept screening (P < 0.05) but women with clinical depression were more likely to refuse 43% of this group would accept compared with 52% of those without depression (P < 0:05; Table 2). Acceptance of screening was significantly influenced by the level of physical disability, with 58% of women with no disability but only 34% with severe disability prepared to attend (P < 0:0001; Table 2). Table 2. Potential uptake of breast screening in previously unscreened older women Response to breast screening if offered... Would accept Would refuse...... Number % Number %... Age (years) n ¼ 1493; P < 0:0001 65 9 229 67 114 33 70 9 410 53 362 47 80 103 27 275 73 Social class, n ¼ 1455; P < 0:05 I 28 62 17 38 II 120 53 107 47 III 441 49 455 51 IV 105 52 98 48 V 29 35 55 65 Marital status, n ¼ 1493; P < 0:0001 Married 350 60 229 40 Single 40 40 61 60 Separated/divorced 28 52 26 48 Widowed 324 43 435 57 Living arrangements, n ¼ 1493; P < 0:0001 Alone 308 46 367 54 Spouse only 305 61 194 39 Spouse + others 45 54 38 46 Others 84 36 152 64 Anxiety, n ¼ 1465; P < 0:05 Present 206 56 164 44 Absent 532 49 563 51 Depression, n ¼ 1465; P < 0:05 Present 83 43 110 57 Absent 655 51 617 49 Disability, n ¼ 1492; P < 0:0001 None 180 58 130 42 Some 346 54 299 46 Appreciable 114 47 127 53 Severe 101 34 195 66 NS, not significant Discussion The size and randomization of the sample, together with a high response rate, ensure that the findings are representative and applicable to the general population of women aged 65 years and over. In the UK, women aged 65 years and over receive breast screening only on demand: we were therefore not surprised to find that only 120 women (8%) had been screened. Undoubtedly some of the women questioned had previously been invited but had declined to attend. Age Concern quotes attendance rates of 6.8% amongst women aged 65 69 years in South Wales [22]. In keeping with previous findings, younger women (aged 65 69 years) were more likely to have had breast screening presumably reflecting the relatively recent introduction of the breast screening programme [10]. We found a significant association between previous uptake of breast screening and being married or having been married and now being separated or divorced. There was also a significant association with currently living with a spouse. Contrary to previous research, we found no significant association between social class and previous breast screening [10]. Of women aged 65 years and over who had never previously attended for screening, half said that they would do so were it offered. Theoretically, a discrepancy may exist between expressed views and future attendance. However, our rates for potential uptake are similar to rates of actual uptake by older women in previous studies of breast cancer screening. The Manchester study of women aged 65 69 years reported an uptake rate of 61% [23] and the Inverness study found that three-quarters of women aged 65 69 years invited to attend for screening actually did so [24]. Preliminary results of a pilot study under way in East Sussex are promising, with an uptake rate of 76% in those women aged 65 69 years who were invited for screening [25]. We also found that the very old were less likely to accept breast screening: two-thirds of those aged 65 69, half of those aged 70 79, but only one-quarter of those aged 80 years and over would accept screening. The uptake of breast screening in Wales in women aged 50 64 years in 1996 7 was 77% (personal communication). Our potential uptake rate of 67% in women aged 65 69 years is therefore comparable to the proportion of younger women who currently accept their invitation for breast screening. Previous studies have indicated that women over 64 of higher social classes are more likely to request breast screening and to have undergone screening at some time [10]. There may be an increased awareness of cancer in the higher social classes (similar to that observed in the uptake of cervical screening). Generally, women over 65 are less aware that breast cancer incidence increases with age. A Gallup poll 133

N. I. Edwards, D. A. Jones revealed that 36% of respondents aged 65 and over did not consider themselves very much at risk while 28% felt that there was no risk to them [10]. Living arrangements significantly influenced willingness to attend for breast screening. Perhaps some husbands encourage their wives to undergo screening. Those women prepared to accept screening were less likely to be depressed, but more likely to be anxious. However, current anxiety and depression may not reflect mental state when previously screened. Severe physical disability appears to be a barrier to uptake in elderly women. Problems of mobility and access may explain this. The implications of this must be considered when developing policy and future practice. Our study confirms that exclusion of older women from routine breast screening on the grounds that only a few will attend appears to be fundamentally flawed: of previous non-attenders aged 65 69 years, over twothirds were likely to accept breast screening if offered. If the upper age range for breast screening is raised, certain categories of women could be specifically targeted in order to achieve maximum acceptance (for example those of the lower social classes, and disabled and single women). With increased prevalence of breast cancer in older women [2] and effectiveness and tolerance of treatment regimens in this age group [26], the current policy raises the issue of inequity of health care provision. Excluding older women from routine breast screening is difficult to justify on the basis of poor assumed attendance rates. We suggest that older women should be considered for breast screening. Key points The incidence and mortality from breast cancer are greatest in women over 65. In women aged 65 years and over, 8% had previously been screened. Amongst previous nonattenders, there is an overall potential uptake rate of 50%, with two-thirds of women aged 65 69 and a half of those aged 70 79 saying they would attend. Those women prepared to attend for screening are more likely to be married, separated or divorced, of higher social class, living with a spouse and suffering from anxiety. Women who are disabled or depressed are less prepared to attend. It is not justifiable to exclude older women from routine breast screening on the false premise that only a minority will attend. Acknowledgements We should like to thank Mark Chamberlain (computing) and Mike Plant (word processing), our interviewers and the many respondents who so generously gave of their time. References 1. Wilson J, Junger G. Principles and Practice of Screening for Disease. World Health Organisation Public Health Paper 34. Geneva: WHO, 1968. 2. Office of Population Census and Surveys. Mortality Statistics 1991: London: HMSO, 1993. 3. Muir C, Waterhouse J, Mack T et al. Cancer Incidence in Five Countries. Volume V. Scientific Publication no. 88. Lyon: IARC, 1987. 4. Breast Cancer Screening. Report to the Health Ministers of England, Wales, Scotland, and Northern Ireland by a Working Group Chaired by Professor Sir Patrick Forrest. London: HMSO, 1986. 5. Horton DA. Breast cancer screening of women aged 65 or older. A review of the evidence on specification effectiveness and compliance. The Breast 1993; 2: 64 6. 6. Harris JR, Lippman ME, Veronesi U et al. Breast cancer (first of three parts). N Engl J Med 1992; 327: 319 28. 7. Hankey BF, Miller B, Curtis R et al. Trends in breast cancer in younger women in contrast to older women. J Natl Cancer Inst Monogr 1994; 16: 7 14. 8. Tabar L, Fagerberg CJ, Gad A et al. Reduction in mortality from breast cancer after mass screening with mammography. Randomised trial from the Breast Cancer Working Group of the Swedish National Board of Health and Welfare. Lancet 1985; i: 829 32. 9. Verbeek A L, Hendricks JH, Holland R et al. Reduction of breast cancer mortality through mass screening with modern mammography. First results of the Nijmegen Project 1975 81. Lancet 1984; i: 1222 4. 10. Not At My Age: why the present breast screening system is failing women aged 65 or over. London: Age Concern England, 1996. 11. Breast Cancer Services. The submission of Age Concern England to the inquiry of the House Of Commons Health Committee. Age Concern Briefing Paper 0395, February 1995. 12. Tabar L, Fagerberg G, Duffy SW et al. Update of the Swedish twocounty programme of mammographic screening for breast cancer. Radiol Clin North Am 1992; 30: 187 210. 13. Van Dijck JAAM, Holland R, Verbeek ALM et al. Efficacy of mammographic screening in the elderly, a case reference study in the Nijmegen programme in the Netherlands. J Natl Cancer Inst 1994; 86: 934 8. 14. Chen H-H, Tabar L, Fagerberg G et al. Effect of breast cancer screening after age 65. J Med Screening 1995; 2: 10 4. 15. Elixhauser A. Costs of breast cancer and the cost effectiveness of breast cancer screening. Int J Tech Assess Health Care 1991; 7: 604 15. 16. Van der Mass PJ, de Koning HJ, van Inveld BM et al. The cost effectiveness of breast cancer screening. Int J Cancer 1989; 43: 1055 60. 17. Breast Cancer Services. Health Select Committee Third Report. London: HMSO, 1995. 18. Jones D, Lester C, West R. Monitoring changes in health services for older people. In: Robinson R, LeGrand J eds. Evaluating NHS Reforms. London: King s Fund Institute, 1994. 19. Webber R, Craig J. Socio-economic Classification of Local Authority Studies on Medical and Population Subjects, no. 35. London: OPCS, 1978. 20. Townsend P. Poverty in the United Kingdom. Harmondsworth: Penguin, 1978. 134

Breast cancer screening 21. McNab A, Phillip AS. Screening an elderly population for psychological well-being. Health Bull 1980; 160 5. 22. Breast Screening and Older Women: regional statistics. Age Concern England Briefing Paper 1896, July 1996. 23. Hobbs P, Kay C, Friedman EH et al. Response by women aged 65 79 to invitation for screening for breast cancer by mammography: a pilot study. Br Med J 1990; 301: 1314 6. 24. Hendry PJ, Entwistle C. Effect of issuing an invitation for breast cancer screening to women aged 65 9. J Med Screening 1996; 3: 88 9. 25. Rubin G, Garvican L, Moss S. Routine invitation of women aged 65 9 for breast cancer screening: results of first year of pilot study. Br Med J 1998; 317: 388 9. 26. Bergman L, Dekker G, van Leeuwen FE et al. The effect of age on treatment choice and survival in elderly breast cancer patients. Cancer 1991; 67: 227 34. Received 8 February 1999; accepted in revised form 28 June 1999 135